Method and prosthesis for percutaneous hernia repair

ABSTRACT

A method and prosthesis is provided for percutaneous repair of an anatomical defect, such as an inguinal hernia. The method involves percutaneously accessing the inguinal canal of a patient. Following hernia reduction, if required, the hernia defect may be accessed and repaired percutaneously from within the inguinal canal. An implantable prosthesis may be percutaneously delivered into the inguinal canal. The prosthesis may be advanced along the inguinal canal from the percutaneous entry location to the defect site, where it may be deployed over and/or within the defect. A biocompatible foam material may be percutaneously delivered into the inguinal canal to reduce and/or repair the hernia defect. The foam may fill and solidify to in the canal to prevent abdominal viscera from reentering the canal. Ablative therapy may be performed within the inguinal canal to cause a fibrotic response resulting in scar tissue formation and/or tissue shrinkage that narrows the canal.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. application Ser. No.14/009,632, filed on Feb. 13, 2014, which is a 371 U.S. National StageApplication of International Application No. PCT/IB2012/000820, filed onApr. 11, 2012, which claims the benefit of U.S. Provisional ApplicationSer. No. 61/474,023, filed on Apr. 11, 2011, each of which is hereinincorporated by reference in its entirety.

FIELD

The present invention relates to a method and implantable prosthesis forpercutaneous hernia repair.

BACKGROUND

Various techniques are known for repairing tissue and muscle walldefects, including hernia defects such as inguinal and ventral hernias.Such repair procedures typically employ open surgical or laparoscopictechniques. A hernia repair may involve the use of an implantableprosthesis, such as a mesh plug and/or patch, that is employed to plugand/or cover the defect.

SUMMARY

The present invention relates to a method and/or prosthesis forpercutaneous repair of an anatomical defect, such as a tissue or musclewall defect. The method and/or prosthesis may have particularapplication for percutaneous repair of an inguinal hernia defect.

In one embodiment, a method involves percutaneously accessing aninguinal canal of a patient. Following reduction of the hernia, ifrequired, the hernia defect may be accessed and repaired percutaneouslyfrom within the inguinal canal.

According to one aspect, the method may involve percutaneouslydelivering an implantable prosthesis into the inguinal canal. Theprosthesis may be advanced along the inguinal canal from the location ofthe percutaneous entry toward the defect, and placed at the defect.

According to another aspect, the method may involve percutaneouslydelivering a biocompatible foam material into the inguinal canal.

According to a further aspect, the method may involve percutaneouslyperforming ablative therapy within the inguinal canal sufficient tocause a fibrotic response that results in scar tissue formation and/ortissue shrinkage that narrows the canal.

The method of percutaneously repairing the hernia defect may involve anyone or combination of an implantable prosthesis to plug and/or cover thedefect, a biocompatible material to fill the inguinal canal, andablation therapy to produce tissue scar formation and/or tissueshrinkage in the inguinal canal.

BRIEF DESCRIPTION OF DRAWINGS

Various embodiments of the invention will now be described, by way ofexample, with reference to the accompanying drawings, in which:

FIGS. 1-8 are schematic illustrations of a method of percutaneouslyrepairing an inguinal hernia according to one embodiment of theinvention;

FIG. 9 is an illustration of a hernia repair patch according to oneembodiment of the invention;

FIG. 10 is an illustration of a hernia repair patch according to anotherembodiment of the invention; and

FIGS. 11-12 are schematic illustrations of a method of percutaneouslyrepairing an inguinal hernia according to another embodiment of theinvention.

DETAILED DESCRIPTION

A method and an implantable prosthesis are provided for percutaneouslyrepairing an anatomical defect, such as a tissue or muscle wall defect.The procedure and device may be particularly suited for repairing aninguinal hernia by providing percutaneous access through a patient'sskin and into the inguinal canal to repair the hernia defect. In thismanner, the procedure may be performed without having to make a surgicalincision into the patient.

Percutaneous access to the defect site, such as the inguinal canal, maybe accomplished using a needle, a guidewire, and a sheath. Moreparticularly, the needle may be percutaneously introduced through theskin and into the inguinal canal, followed by the introduction of theguidewire through the needle. The needle is thereafter removed and thesheath is subsequently introduced over the guidewire into the inguinalcanal. If desired, a dilator may be employed to facilitate introductionof the sheath. After placement of the sheath, the guidewire, and thedilator if used, may be removed with the sheath remaining in place toprovide direct percutaneous access to the inguinal canal, or otherdefect site, for repairing the defect. In this regard, the methodinvolves use of a Seldinger-like technique to percutaneously access theinguinal canal.

Once access to the inguinal canal has been established, the hernia maybe reduced, if necessary. Reduction of the hernia may be accomplishedusing one or more techniques including, but not limited to, insertion ofa finger through the sheath, injection of a foam, gel or fluid, such asgas or liquid, through the sheath, and/or the introduction of a surgicaltool, such as a surgical balloon, to push the hernia from the inguinalcanal. With the contents of the inguinal canal reduced, repair of thehernia defect may be carried out percutaneously through the sheath.

The hernia defect may be repaired with an implantable prosthesis that isintroduced into the inguinal canal, or other defect site, through thesheath. Once introduced, the prosthesis may be advanced from thepercutaneous access location and along the canal to the site of thedefect, where it may then be placed over, into or through the defect.

The prosthesis may include a plug and/or patch configured to be placedinto and/or over the defect. The prosthesis may be collapsible orcompressible to a reduced or slender configuration for passage throughthe sheath. The prosthesis may be expandable to an open, deployed orexpanded configuration for plugging, capping or covering the defect. Theprosthesis may include one or more features to facilitate deploymentand/or expansion.

The prosthesis may include a distal patch that is advanced from theinguinal canal through and beyond the hernia defect in a collapsedconfiguration. The patch may thereafter be opened or expanded so that iscan be deployed over the defect. Once expanded, the patch may beretracted back and positioned against the distal or posterior surface ofthe abdominal wall to cover the defect. For repairing an indirectinguinal hernia, the patch may be advanced through and deployed over theinguinal ring.

Once deployed, it may be desirable to anchor or secure the patch inposition over the defect. The prosthesis may include an elongated tetheror cord that is attached to and extends from the patch. The cord may bepulled and/or tensioned to hold the patch in position against theabdominal wall. An end of the cord opposite the patch may be anchoredproximally to maintain the patch against the wall at the hernia defect.The prosthesis may include a proximal anchor that is to be attached tothe cord to anchor the patch. The proximal anchor may be configured forsubcutaneous placement. The patch may include one or more features, suchas projections, hooks, barbs or anchors, that extend from one or moreregions of the patch to grip tissue adjacent the hernia defect andstabilize the patch in position.

The distal patch may employ any configuration suitable for theanatomical region of the hernia defect. In one embodiment, the patch mayhave an oval shape for covering the internal inguinal ring, althoughother configurations are contemplated. The patch may include one or morefeatures for accommodating anatomical features or sensitive structuresoccupying the repair site. In one embodiment, the patch may include anindentation, notch or other relief along its periphery for accommodatinginguinal nerves and/or the spermatic cord.

For some repair procedures, a biocompatible foam material may beintroduced into the inguinal canal to reduce and/or repair the herniadefect. The foam may be injected into the canal to reduce the hernia andsolidify in the canal. The foam may permanently or temporarily fill thecanal to prevent abdominal viscera from reentering the canal. The foammay solidify to fill the three-dimensional shape of the canal andthereby resist upward migration into the abdomen.

The foam may be formed of any suitable non-absorbable material orabsorbable material, such as collagen, as should be apparent to one ofskill in the art. If desired, the foam may be formed of a radiopaquematerial.

For an indirect inguinal hernia, foam may be injected until the canal isfilled to the internal inguinal ring. If desired, the foam may be cappedor covered distal to the internal inguinal ring using either a permanentor temporary cap or patch. In one embodiment, the foam may be used inconjunction with the distal patch and the proximal anchor, whereby thefoam is located between the patch and the anchor. In another embodiment,the foam may be capped using a distal patch that is positioned over theinternal inguinal ring.

For some inguinal hernia repair procedures, reduction of the hernia maybe followed by ablative therapy within the inguinal canal that issufficient to cause a fibrotic response resulting in scar tissueformation and/or tissue shrinkage that narrows the canal. The ablativetherapy may involve full or partial circumferential ablation of thecanal. If desired, tissue ablation may extend circumferentially about alimited region of the canal to avoid ablation at regions of nerves orother sensitive structures within the canal. Ablation may be performedunder direct visualization, such as by using a fiber optic device, toavoid damage to or ablation of nerves or other sensitive structurespresent in the inguinal canal. Ablation may be performed using anysuitable ablative device as should be apparent to one of skill in theart.

Ablation may be performed in conjunction with an implantable prosthesisto plug and/or cover the defect in the inguinal canal. The prosthesismay include a distal plug and/or patch. If desired, the plug or patchmay be held in position using a tether alone or together with a proximalanchor, such as described above.

The procedure may be carried out under a sterile technique using a localanesthesia and conscious sedation. An interventional radiologist or aminimally invasive surgeon may perform the procedure. The repairprocedure may be performed under fluoroscopic or ultrasonic to guidance,under internal light emission, or even without imaging.

One illustrative embodiment of a method for percutaneous repair of aninguinal hernia is described below in conjunction with FIGS. 1-10. It isto be appreciated, however, that one or more aspects of the method maybe employed to percutaneously access and repair other anatomical defectsas should be apparent to one of skill in the art.

As shown in FIG. 1, a needle 20 is percutaneously introduced into theinguinal canal 22, preferably using a sterile technique. As illustrated,the needle 20 may be introduced at a region 24 of the inguinal canallocated laterally away from the hernia defect 26. Introduction of theneedle may be carried out under a local anesthesia and conscioussedation, although other suitable anesthetic techniques are contemplatedas should be apparent to one of skill in the art. In one embodiment, theinguinal canal is accessed with a hollow 16-gauge beveled needle.However, the inguinal canal may be accessed using any suitable needle orother device as should be apparent to one of skill in the art.

As shown in FIG. 2, a contrasting agent 28 may be injected through theneedle 20 to confirm the anatomical location of the needle tip 30 withinthe inguinal canal 22. The contrast agent 28 may also be used to definethe anatomical boundaries of the inguinal canal, including the locationof the inguinal ring 32. The contrasting agent may be a radiographiccontrast agent, such as a liquid or paste, that is injected through theneedle under fluoroscopy in a manner known to one of skill in the art.

As shown in FIG. 3, a guidewire 34 or exchange wire may be introducedinto the inguinal canal 22 through the needle 20, for example, underfluoroscopic guidance. As illustrated, the guidewire 34 may be extendedalong a portion of the canal in a lateral direction toward the inguinalring 32. After the guidewire 34 has been positioned at its desiredlocation, the needle is removed while maintaining the guidewire in theinguinal canal 22, as shown in FIG. 4.

As shown in FIG. 5, an introducer sheath 36 may be introduced into theinguinal canal 22 over the guidewire 34. As illustrated, the tip 38 ofthe sheath 36 may be directed laterally (FIG. 6) in the canal towardsthe inguinal ring 32. The sheath 36 may include a side arm 40 that canbe employed to inject additional contrast during the repair procedure tofurther delineate the anatomy, if desired. The side arm 40 may also beused to irrigate and aspirate the site, and inject a prophylacticantibiotic solution into the site, if desired, prior to removal of thesheath.

To facilitate the introduction of the sheath 36 into the canal, adilator may be used in conjunction with the sheath in a manner as shouldbe apparent to one of skill in the art. In one embodiment, a balloondilator may be advanced along the guidewire prior to the introduction ofthe sheath.

The sheath 36 may be flexible and/or precurved to facilitateintroduction and placement of the sheath tip 38 in the inguinal canal.Alternatively, the sheath may be actively deflectable with a radiopaqueringed soft tip. The sheath may include one or more lumens or passagesto provide access to the inguinal canal and allow for the introductionof an optical visualization device, surgical tools and/or implantableprostheses for repairing the defect.

When the sheath 36 is placed in its desired position and the guidewireis no longer needed in the inguinal canal, the guidewire 34 may beremoved from the sheath. A surgeon now has direct access to the inguinalcanal through the sheath for reducing and/or repairing the herniadefect.

In one embodiment, a foam, gel or fluid, such as gas or liquid, may beinjected through the sheath and into the inguinal canal to reduce thehernia. If desired, the reduction medium may be injected through theside arm of the sheath.

In one embodiment, a surgical tool may be introduced through the sheathto push the hernia from the inguinal canal. If desired, the tool may beintroduced over the guidewire to reduce the hernia, prior to removingthe guidewire from the sheath. The tool may include a surgical balloon,such as a round ball-type balloon, that pushes back the hernia sack asit is advanced along the guidewire.

In one embodiment, a surgeon may insert a finger through the sheath andreduce the contents of the inguinal canal.

It is to be appreciated that a surgeon may employ any one or acombination of these and/or other techniques to reduce the contents ofthe inguinal canal as should apparent to one of skill in the art.

Once the hernia has been reduced from the inguinal canal, the defect maybe percutaneously repaired to prevent or minimize recurrence of thehernia. In one illustrative embodiment shown in FIG. 6, a prosthesis 42may be introduced through the sheath 36 and into the inguinal canal 22.Once placed in the inguinal canal, the prosthesis 42 is advancedlaterally along the canal 22 from the percutaneous access location 24 tothe hernia defect 26. For an indirect inguinal hernia, the prosthesis isadvanced to the inguinal ring 32.

As illustrated in FIG. 7, advancement of the prosthesis 42 may continuethrough and beyond the internal inguinal ring 44. The prosthesis maythereafter be positioned to cover the defect. In one embodiment, theprosthesis 42 may include an expandable distal plug and/or patch 46 thatis expandable to an enlarged deployed or open configuration after theplug or patch has been advanced beyond the defect. The expanded plug orpatch 46 may thereafter be retracted or seated against the abdominalwall to cover or cap the internal inguinal ring.

In one illustrative embodiment shown in FIGS. 7-8, the prosthesis 42 mayinclude a cord or tether 48 that is attached to the distal plug or patch46 to facilitate placement and anchoring of the plug or patch over thedefect. As shown, the cord 48 may have a length sufficient to extendfrom the plug or patch 46 through the sheath 36 and outside the patientso that a surgeon may manipulate and pull the cord to retract and seatthe plug or patch 46 against the abdominal wall.

Once the distal plug or patch 46 has been positioned and seated, it maybe anchored proximally via the cord 48 to prevent the plug or patch frommoving away from the inguinal ring. In one embodiment shown in FIG. 8,the prosthesis may include a proximal anchor 50 that is attached to aproximal end of the tether 48 which is placed under tension to maintainthe distal plug or patch 46 in position against the defect. As shown,the anchor 50 may be positioned subcutaneously at the percutaneousentrance 24 to the inguinal canal after removal of the sheath.

The prosthesis may include a distal plug and/or patch 46 having aconfiguration suitable for covering and/or sealing the defect as shouldbe apparent to one of skill in the art. In one embodiment, theprosthesis may include an umbrella-like patch that is collapsible into aslender configuration to facilitate introduction through the sheath andadvancement along the inguinal canal and through the inguinal ring. Thedistal patch is expandable to an open or deployed configuration that hasa shape and/or size that is sufficient to cap, cover or plug the defect.

In illustrative embodiments shown in FIGS. 9-10, the patch 46 may havean oval or round shape. For some applications, it may be desirable toaccommodate sensitive structures, such as inguinal nerves and/or thespermatic cord, occupying the inguinal space. As shown, the patch 46 mayinclude an indentation, notch or other relief 52 along its periphery 54that is configured to receive adjacent anatomical structure when thepatch is positioned at the defect site. However, a relief is notrequired for all embodiments of the patch, and the patch may have anyconfiguration or shape suitable for capping, covering or plugging thedefect as should be apparent to one of skill in the art.

To facilitate deployment of the prosthesis, the patch 46 may include oneor more support members that expand and/or support the patch in an openor deployed configuration. In one embodiment shown in FIG. 10, the patch46 may include one or more arms, struts or spokes 56 that extend in anoutward radial direction from the central region of the patch toward theouter periphery 54 of the patch. In this manner, the patch 46 may beprovided with a frame-like structure to open and/or deploy the patch.

It is to be appreciated that the prosthesis may employ any suitablesupport member configuration as should be apparent to one of skill inthe art. For example, the support members may include one or moreresilient rings, such as concentric rings, to open or deploy the patch.

The support members 56 may be formed of a shape memory or superelasticmaterial, such as nitinol, that allows the members to transform from acollapsed configuration to an expanded configuration to expand or openthe patch. If desired, the support members may be formed of a radiopaquematerial to assist with introducing and guiding the prosthesis to thedefect site. However, any suitable material as should be apparent to oneof skill in the art may be used for the support members.

The patch may include one or more anchors to maintain and/or stabilizethe patch at the defect site. In illustrative embodiments shown in FIGS.9-10, the patch 46 may include a plurality of anchors 58 that are spacedabout the patch to penetrate, grasp or grip tissue at the defect site.The anchors 58 may include hooks that are located about the periphery 54of the patch. In one embodiment shown in FIG. 10, the anchors 58 mayextend from the ends of the support members 56. It is to be appreciatedthat anchors are not required for each embodiment of the prosthesis, andthat the anchors, if desired, may include any suitable configuration asshould be apparent to one of skill in the art.

The prosthesis may include a proximal anchor 50 having any configurationapparent to one of skill in the art that is suitable for maintainingtension on the cord 48 to hold the distal patch 46 in position at thedefect. In one embodiment, the prosthesis may include an anchor disc 50that is secured to the proximal end of the tether 48. The anchor discmay be configured for subcutaneous placement in a patient. Otheranchoring devices may include, but are not limited to, a hinged T-bar, arollable button, a staple and a suture.

The distal patch, the tether and the proximal anchor may be formed ofany biocompatible material suitable for hernia repair as should beapparent to one of skill in the art. The patch, tether and anchor mayinclude absorbable, non-absorbable or a combination of absorbable andnon-absorbable materials. In one embodiment, the patch may be formed ofa collagen material that is resorbable over a predetermined period oftime.

For some repair procedures, it may be desirable to introduce abiocompatible material, such as a foam, into the inguinal canal toreduce and/or repair the hernia defect. The foam may be used eitheralone or with an implantable prosthesis to repair the defect.

In one illustrative embodiment shown in FIG. 11, a foam material 60 maybe injected into the canal 22 through the sheath 36. For an indirectinguinal hernia, the foam 60 may be injected until the canal is filledto the internal inguinal ring 44. The foam 60 may be capped distal tothe internal inguinal ring using either a permanent or temporary cap orpatch 46.

As illustrated, the foam 60 may be introduced into the inguinal canal 22after a distal patch 46 has been positioned over the internal inguinalring 44, such as in a manner described above. The distal patch 46 may beheld in position over the inguinal ring using a tether 48 as the foam isbeing introduced into the canal.

As illustrated in FIG. 12, the distal patch 46 may be anchored inposition using a proximal anchor 50 that is attached to a proximal endof the tether 48 which is placed under tension to maintain the distalplug or patch in position against the defect. The anchor 50 may beattached to the tether 48 and positioned subcutaneously, as shown, atthe percutaneous entrance 24 to the inguinal canal after introduction ofthe foam and removal of the sheath. As shown, the foam 60 is locatedbetween the patch 46 and the anchor 50. However, if desired, the foammay be capped using only a distal patch that is positioned over theinternal inguinal ring.

The foam 60 may permanently or temporarily fill the canal 22 to preventabdominal viscera from reentering the canal. The foam may solidify tofill the three-dimensional shape of the canal and thereby resist upwardmigration into the abdomen. The foam may be formed of any suitablenon-absorbable material or absorbable material, such as collagen, asshould be apparent to one of skill in the art. If desired, the foam maybe formed of a radiopaque material.

In one embodiment, the foam may be injected into and contained within arolling membrane, such as a compliant sliding balloon. The membrane maybe formed of any suitable non-absorbable material or absorbablematerial, such as collagen, as should be apparent to one of skill in theart.

It should be understood that the foregoing description of variousembodiments of the invention are intended merely to be illustrativethereof and that other embodiments, modifications, and equivalents ofthe invention are within the scope of the invention recited in theclaims appended hereto. Further, the methods and prostheses describedabove include various aspects and/or features that may be employedsingularly or in any suitable combination.

What is claimed is:
 1. A method of percutaneously repairing an inguinalhernia defect, the method comprising acts of: (a) percutaneouslyaccessing an inguinal canal of a patient; (b) percutaneously deliveringa biocompatible foam material into the inguinal canal.
 2. The methodaccording to claim 1, wherein act (b) includes filling the inguinalcanal with the foam material from the location of percutaneous accesstoward the hernia defect.
 3. The method according to claim 2, whereinact (b) includes filling the inguinal canal to the inguinal ring.
 4. Themethod according to claim 1, wherein the foam material solidifies in theshape of the inguinal canal.
 5. The method according to claim 1, furthercomprising an act (c) of percutaneously plugging and/or covering thehernia defect with an implantable prosthesis.
 6. The method according toclaim 5, wherein act (c) occurs prior to act (b).
 7. The methodaccording to claim 5, wherein act (c) includes percutaneously deliveringthe prosthesis into the inguinal canal, and advancing the prosthesisalong the inguinal canal from the location of percutaneous access towardthe hernia defect.
 8. The method according to claim 7, wherein act (c)includes advancing the prosthesis through the hernia defect.
 9. Themethod according to claim 7, wherein act (c) includes collapsing theprosthesis to a first configuration for delivering and advancing theprosthesis, and expanding the prosthesis to a second configuration thatis larger than the first configuration to plug and/or cover the herniadefect.
 10. The method according to claim 5, wherein act (c) includesplacing the prosthesis against a distal side of the hernia defect. 11.The method according to claim 5, wherein the prosthesis includes a patchthat is collapsible into a slender configuration for percutaneousdelivery into and advancement along the inguinal canal.
 12. The methodaccording to claim 11, wherein the prosthesis includes a tetherextending from the patch, and wherein act (c) further includestensioning the tether to draw the to patch over the hernia defect. 13.The method according to claim 12, wherein act (c) includes anchoring thetether to maintain the patch in position over the hernia defect.
 14. Themethod according to claim 12, wherein the prosthesis includes a proximalanchor, and wherein act (c) includes attaching the tether to theproximal anchor.
 15. The method according to claim 14, wherein theproximal anchor is subcutaneously located proximate the percutaneousaccess.
 16. The method according to claim 5, wherein the hernia defectis an indirect inguinal hernia, and wherein act (c) includes placing theprosthesis over the inguinal ring.
 17. The method according to claim 1,wherein act (a) includes establishing percutaneous access to theinguinal canal using a Seldinger-like procedure.
 18. A method ofpercutaneously repairing an inguinal hernia defect, the methodcomprising acts of: (a) percutaneously accessing an inguinal canal of apatient; (b) percutaneously performing ablation therapy within theinguinal canal sufficient to cause a fibrotic response that results inscar tissue formation and/or tissue shrinkage that narrows the inguinalcanal.
 19. The method according to claim 18, wherein act (b) includescircumferential ablation of at least a portion of the inguinal canal.20. The method according to claim 18, wherein act (b) includes partialcircumferential ablation of the portion of the inguinal canal.
 21. Themethod according to claim 18, wherein act (b) includes avoiding ablationof regions of nerves within the inguinal canal.
 22. The method accordingto claim 18, further comprising an act (c) of percutaneously pluggingand/or covering the hernia defect.
 23. The method according to claim 22,wherein act (c) includes percutaneously delivering the prosthesis intothe inguinal canal, and advancing the prosthesis along the inguinalcanal from the location of percutaneous access toward the hernia defect.24. The method according to claim 23, wherein act (c) includes advancingthe prosthesis through the hernia defect.
 25. The method according toclaim 23, wherein act (c) includes collapsing the prosthesis to a firstconfiguration for delivering and advancing the prosthesis, and expandingthe prosthesis to a second configuration that is larger than the firstconfiguration to plug and/or cover the hernia defect.
 26. The methodaccording to claim 22, wherein act (c) includes placing the prosthesisagainst a distal side of the hernia defect.
 27. The method according toclaim 22, wherein the prosthesis includes a patch that is collapsibleinto a slender configuration for percutaneous delivery into andadvancement along the inguinal canal.
 28. The method according to claim27, wherein the prosthesis includes a tether extending from the patch,and wherein act (c) further includes tensioning the tether to draw thepatch over the hernia defect.
 29. The method according to claim 28,wherein act (c) includes anchoring the tether to maintain the patch inposition over the hernia defect.
 30. The method according to claim 28,wherein the prosthesis includes a proximal anchor, and wherein act (c)includes attaching the tether to the proximal anchor.
 31. The methodaccording to claim 30, wherein the proximal anchor is subcutaneouslylocated proximate the percutaneous access.
 32. The method according toclaim 22, wherein the hernia defect is an indirect inguinal hernia, andwherein act (c) includes placing the prosthesis over the inguinal ring.33. The method according to claim 18, wherein act (a) includesestablishing percutaneous access to the inguinal canal using aSeldinger-like procedure.